One thing that sets Texas Perinatal Services apart is its 100 percent Texas-based, Texas-experienced surveyors. In our ongoing series of Conversations with TPS Surveyors, we are pleased to introduce another one of our exceptional maternal surveyors, Kathleen Rasmussen, M.D., Ph.D.
Her two decades of OB/GYN experience span all levels of care delivery, from private practice to clinical leadership roles across the Corpus Christi region. We recently talked with her about the new maternal care verification surveys and what hospitals can expect.
It’s coming up on one year since the state’s new maternal levels of care designation rules came into effect. In this first year, what has been the greatest impact of the rules in your perspective?
The rules are very specific about what the hospitals need to do and to provide if they are going to be designated at each level. That has been very helpful. It is making all hospitals really look at those rules carefully and be sure they are providing at that level. We never had to do that before. Here locally, our facilities are viewing these like Joint Commission surveys. We want to be prepared, be able to show what we are doing, and make sure we have very good documentation.
Why did you choose to become a surveyor?
I gave it a lot of thought because I have a lot on my plate. But to be honest, the data that has come out about Texas’ high rate of maternal morbidity and mortality compared to other states really bothered me. I felt that by saying yes to being a surveyor, I could be a part of making a difference. It’s also a great opportunity for me to see what other hospitals in the state are doing, and bring that back to my facility.
I knew of TETAF because we have a Level 2 trauma center and a stroke center, and have been surveyed by TETAF. Our facility has great respect for TETAF, and I feel honored to be a part of the organization.
How would you describe your role as a surveyor – what is your focus, and what is a typical day like while onsite conducting a survey?
TETAF did a great job of getting us ready as surveyors. They reviewed the rules for us, explaining them so that we could be confident in explaining them ourselves as surveyors. We also went over the tools that we would use the day of the survey, and received good training on what we are supposed to do when we go into a facility.
Our goal as TETAF/TPS surveyors is to be very objective. The first day it’s all business – chart reviews, policies, procedures, documentation, outcomes, asking a lot of questions. The first day is very intense. We finish up in the early evening, and then the surveyors meet as a group to go over that first day.
The second day is a question-answer format to go over concerns from the day before. We then also address all of the services — laboratory, radiologists, pharmacists, behavioral, clerical, and so on. The hospital administration is there, physician leaders are there. Our focus is on seeing if they are following their policies and procedures, and whether the hospital is following what the rules require. A part of our role is making the hospital aware of where it has potential deficiencies, and helping clarify the rules for the staff.
Then we have a closing session where we meet with the leadership team. We emphasize the hospital’s strengths, review what we saw as weaknesses, and make recommendations on how the hospital could improve. We are there to help the hospital, and to bring them up to the top of their game. We want all the maternal care facilities to do that. Our focus is not to be punitive but to help the hospital be where and what it wants to be.
We’ve heard a lot about the importance of hospitals planning ahead for their survey. What steps have you seen that worked particularly well to help a hospital be very well prepared?
Readiness of the team on the first day of the survey is critical. Be prepared to show where the data are and where the documentation is. Have your act together, coach and train your staff to be able to do the chart reviews. I would recommend actually practicing some chart reviews in advance. Go through the EHR and the data and be ready to do that during the survey. That helps us be more efficient in getting through the chart reviews, and really sets the tone for organization and planning.
Also, have all the procedures and policies well organized and have a point person there who knows where everything is, and can access anything the surveyors ask for. Have your QAPI minutes very well organized in binders in the room for us, where the surveyors can just pull them off the shelf. Also involve your physicians in the process; the medical director needs to be involved early on, don’t wait until the last minute to get physician involvement. And, most importantly, study the rules. You can’t get away from them, no exceptions.
About Dr. Rasmussen
Texas Perinatal Services maternal surveyor Kathleen Rasmussen, M.D., Ph.D., has been providing women’s health services for two decades. She has been a department chair for OB/GYN departments in Utah, and atChristus Spohn South Hospitals for several years. She also has been the vice president for medical affairs at Spohn for several years. Currently she is the regional director for women’s medical services for Christus Spohn South, Alice, Beeville and Kleberg Hospitals.